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DOI: 10.1177/
Abstract
Objective: This study aimed to assess the application of the Betty Neuman systems model to the care of
patient/clients with multiple sclerosis.
Methods: This clinical study resulted from the application of the nursing process to a patient/client
admitted with multiple sclerosis in the neurological ward of a hospital in an urban area of Iran.
Results: A patient/client was evaluated according to the Neuman model. Intrapersonal stressors (physio-
logical, psychological, socio-cultural, and spiritual), interpersonal stressors (being away from family and
children) and extra-personal stressors (aggression and psychological pressure from the spouse) were
found. Based on the examination, 12 nursing diagnoses based on the taxonomy of the North American
Nursing Diagnosis Association International, and nursing care based on three levels of prevention that
are important in the view of Neuman, are presented. The results were used in the classification of nursing
interventions and the classification and nursing outcomes respectively.
Conclusions: The results suggest the desirability of care and patient/client satisfaction in the evaluation
of nursing care based on the Neuman model. The model can be used as a framework to help nurses care
for patients/clients. Thus, the application of this model and other models is recommended in the nursing
care of patients/clients.
Keywords: Multiple sclerosis, patient/client care, nursing models, Neuman systems model
Correspondence to:
Introduction The goal of early disease management is to intervene Tabandeh Sadeghi
Department of Pediatric
Multiple sclerosis (MS) is an autoimmune disease before irreversible neuronal destruction happens, to Nursing, School of Nursing
of the central nervous system (CNS) characterized delay the progression of disability, and to improve and Midwifery; Non-
Communicable Diseases
by brain inflammation, demyelination, and axonal the quality of life.5 Currently, there is no known cure Research Center, Rafsanjan
loss, which occurs primarily between the ages of for MS, and the treatment goal of MS is the preven- University of Medical
Sciences, Rafsanjan, Iran,
2040 years.1 MS is the most prevalent inflamma- tion of permanent neurological damage.6 Thus, the Jomhori St, Rafsanjan
tory2 and the second most common cause of neuro- nature of the disease poses an obvious need for inter- 7718796755, Iran.
t.b_sadeghi@yahoo.com
logical disability in working-age adults. Since it disciplinary services. Nurses have to play a key role
Zakieh Ahmadi,
usually strikes in the prime of life, frequently pro- in the interaction with patients/clients and their Department of Medical
gresses to disability, and has no cure, MS can have a families to improve the patient/client’s health.7 The Surgical Nursing, School of
Nursing and Midwifery.
strong emotional impact not only on those who purpose of nursing care is to improve the quality of Hormozgan University of
suffer from it, but also on the healthcare team.3 life of patients/clients.8 An effective way to promote Medical Sciences, Bandar
Abbas, Iran
The range of symptoms that occur in MS can have nursing care is by applying nursing theories.9
Tabandeh Sadeghi,
disabling functional consequences for patients and Department of Pediatric
lead to significant reductions in their quality of life The clinical use of nursing models and theories helps Nursing, School of Nursing
and Midwifery; Non-
and the ability of individuals to carry out their roles develop nursing knowledge.10 It is an important step Communicable Diseases
and job tasks.4 to achieve the goals that guide the practical Research Center, Rafsanjan
Creative Commons CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (http://www.creativecommons.org/
licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on
the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
Multiple Sclerosis Journal—Experimental, Translational and Clinical
University of Medical
Sciences, Rafsanjan, Iran
application of clinical and educational research.11 in time. She identifies three relevant environments:
Department of Pediatric A wide variety of situations and phenomena make internal, external, and created.12 The internal influ-
Nursing, Rafsanjan
University of Medical
a certain degree of flexibility necessary in the selec- ences are contained within the boundaries of the cli-
Sciences, Iran tion of the models and nursing theories according to ent’s system in other words, they are intrapersonal in
the circumstances.12 The Betty Neuman systems nature. The external influences exist outside the
model is one theory that provides guidance at three client; and the created environment is unconsciously
levels of prevention.13 developed and is used by the client to support pro-
tective coping.17 She views health as a continuum of
Neuman systems model wellness to illness that is dynamic in nature and is
The Neuman systems model is based on a general constantly changing. Optimal wellness exists when
system theory and reflects the nature of living organ- the total system needs are completely met and illness
isms as open systems in interaction with each other exists at the opposite end of the continuum from
and with the environment. Within the Neuman model, wellness and represents a state of instability and
the client may be an individual, a family, a group, a energy depletion.12
community, or a social entity. An important assump-
tion of the Newman theory is: ‘‘each client system is Neuman believes that nursing is concerned with
unique, a composite of factors and characteristics the whole person. She views nursing as a unique
within a given range of responses.’’13 [p. 285] profession and believes that it is concerned with all
the variables affecting an individual’s response to
The human being is a total person, characterized by stress. The primary aim of nursing is the stability
five variables: these include physiological, psycho- of the client system. This is achieved through nursing
logical, socio-cultural, spiritual, and developmental intervention to reduce the stressors. Neuman’s pro-
variables.14 The physiological variable refers to body cess contains three basic parts: nursing diagnosis,
structure and function. The psychological variable nursing goals, and nursing outcomes. Neuman stres-
refers to mental processes in interaction with the ses the importance of identifying the client’s and the
environment. The socio-cultural variable refers to caregiver’s perceptions and collaboration between
the effects and influences of social and cultural con- the client and the caregiver in all stages of the
ditions. The spiritual variable refers to spiritual process. She identifies three levels of intervention:
beliefs and influences. The developmental variable primary, secondary, and tertiary (Table 1). Primary
refers to age-related processes and activities.13 prevention takes place even before the client system
can respond to a stressor that the purpose is to
An individual organism is said to have a central reduce the possibility of encounter with the stressor.
‘‘core’’ of basic survival mechanisms, such as tem- Secondary prevention takes place after the client
perature control, ego, and organ function.12 The core system responds to a stressor. Tertiary prevention
is protected by lines of defence. The outer layer is the occurs after the active treatment or secondary pre-
flexible line of defence, and is variable, responding to vention stage that it focuses on readjustment toward
the particular stressor. The inner or ‘‘normal’’ line of optimal client system stability.13 This paper demon-
defence represents the state of wellness and adapta- strates the application of the Betty Neuman systems
tion of the individual. It is generally stable. The lines model to the care of patients/clients with MS.
of resistance represent the internal factors that deter-
mine an organism’s response to a stressor. Stressors Method
(intrapersonal, interpersonal, and extra-personal) are This clinical study resulted from the application of
significant to the concept of environment and are the nursing process mediated by the nursing theory
described as environmental forces that interact with, of Betty Neuman to the care of patients/clients with
and potentially alter, system stability.15 Intrapersonal MS in a neurological ward of a hospital in an urban
factors include interactions contained within the area of Iran. One patient was studied in this study.
client, such as conditioned responses. Interpersonal
factors arise from interaction between two or more In the first stage of the nursing process, an interview
individuals, such as role expectation. Extra-personal was drawn up with the purpose of guiding the research
factors comprise all interactions occurring outside the and determining the stressors. This clinical study was
client, such as financial circumstances.16 about single patient.
Neuman defines the environment as all the internal After the assessment and data collection, 12 nursing
and external forces surrounding the client, influen- diagnoses were established according to the tax-
cing and being influenced by the client at any point onomy of the North American Nursing Diagnosis
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Ahmadi and Sadeghi
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Multiple Sclerosis Journal—Experimental, Translational and Clinical
Table 2. Nursing process adapted according to the Neuman theory for the multiple sclerosis (MS) patient/client.
Type of patient/ Nursing diagnoses Aim Level of Interventions
client variable prevention
Physiological Not tolerating any activity Helping the patient/client Secondary Avoiding exposure to environ-
associated with weak- carry out activities ments with high temperatures,
ness, fatigue, and without depending on taking hot showers, eating
irritability others heavy foods, too many activ-
ities, hunger and stress, which
exacerbate fatigue.
Exercise and sports, such as
swimming and simple ges-
tures, as much as tolerated
Reduction in ambient noise
Avoiding too much work, resting
between work periods, and
getting adequate sleep
Compliance with energy saving
techniques, such as sitting
while showering, and brush-
ing teeth
Cold shower, sucking ice, using
ice packs or wet towel, when
feeling hot
Physiological Eating disorder, eating less Improving the quality of Secondary Avoidance of irritant materials
than what the body the patient/client’s and odors
needs, anorexia and appetite, nutrition, and Resting before each meal to
nausea proper diet minimize weakness
Eating in a quiet and clean
environment and devoting
enough time to it
Eating frequent meals in small
amounts
Gentle position-changing to
avoid nausea
Avoiding fatty foods, like butter,
sauces, and nuts
Avoiding fluid intake during
food intake to prevent early
satiety
Avoiding foods that contain
caffeine, such as tea, coffee,
and spicy food.
Physiological Risk of trauma and falls in Avoiding trauma, injury, Primary Availability of necessary sup-
association with visual and controlling the situ- plies, and avoiding disorgan-
and movement dis- ation during weakness ization and chaos
orders, weakness and and dizziness Using appropriate shoes and
dizziness slippers
Sufficient ambient light
Keeping calm and avoiding rush
during work
Avoiding abrupt changes in a
situation to avoid dizziness
Sitting during dizziness
(continued)
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Ahmadi and Sadeghi
Table 2. Continued
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Multiple Sclerosis Journal—Experimental, Translational and Clinical
Table 2. Continued
Some variables including socio-cultural, psychological, and physiological variables may interact, and therefore are not repeated in the table
under the related variable.
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Ahmadi and Sadeghi
Musculoskeletal: weakness in arms and legs, radiat- 2. The patient/client mentioned techniques that
ing pain in the shoulder and chest, imbalance and she was taught to maintain her energy levels.
dizziness during attacks. She became aware of the importance of resting
Hearing: stuffiness in the ear. between activities to avoid boredom and stated
Sight: blurred vision, double vision, fluttering that she would try to consider resting in
objects in the visual field, reduced visual field, between work.
inability to see beyond a distance of about 78 m. 3. When the patient/client became aware of the
impact of stress on the progress of her disease,
she was determined to reduce the amount of
Psychological. The patient/client cannot express any stress in her life. Her family was also consulted
feelings about the disease, but is depressed and anx- and asked to put family tensions aside to help
ious, looks tired and bored. In the case study, irrit- her.
ability and mental pressure by the patient/client’s 4. The patient/client named several types of foods
husband were considered as intrapersonal factors that she should avoid, like fatty and spicy food,
that caused stress. Following stress and family dis- and decided to avoid situations that decreased
sociation, she was constantly agitated and anxious. her appetite, and thus, improved her nutritional
status.
She needed intense mental family support.
5. The patient/client’s awareness of the measures
to avoid trauma caused her to avoid walking
Socio-cultural. The patient/client participates in art-
during vertigo attacks and sit down until she
istic activities and believes that she will be mentally
felt better.
calm. But the patient/client cannot participate in 6. The patient/client named several foods con-
sports classes, held by the MS center, due to prob- taining fiber that helped improve the defeca-
lems of transportation and distance. tion pattern. She stated that she used soaked
figs to improve her situation.
Developmental. She has been successfully engaged 7. With regard to training to prevent fatigue, the
in meeting developmental needs appropriate to a patient/client could do it over time, and also
middle-aged adult, for example: preparing for understood that this could be a reason for her
menopause. spouse’s aggression. So, she decided to pay
more attention to the needs of her husband.
Spiritual. Considers herself a religious person. She 8. The patient/client uses proper coverage and
believes in God and prays. She participates in reli- cooling equipment during sleep. Regarding
gious ceremony. consumption of tea before bedtime, she
decided to cut the use of caffeine.
Interpersonal stressors 9. The patient/client used to go for visual exam-
These include (a) being away from family due to long ination, but the visit intervals were long.
distance; (b) being away from children due to remote Considering the importance of this issue, she
education place; and (c) extra-personal stressors. decided to shorten the intervals of visit and
used protective clothing for her eyes, such as
sunglasses, when she went out into the sun.
Results
10. She stated that she could not use gloves while
The nursing results were used for the classification
using detergents. She decided to bathe in warm
of nursing interventions and the classification of nur- water instead of cold water.
sing outcomes respectively (Table 2). 11. The patient/client stated that she followed all
the necessary hygienic measures to prevent
Discussion urinary tract infections. She also decided to
MS is a chronic disorder with no definite cure. So, limit the consumption of beverages containing
the goal of treatment is to control the signs and caffeine.
symptoms, prevent further progress, and ensure 12. According to the patient/client’s statement, she
better compliance from the patient/client. had the enthusiasm and interest to continue
participating in training classes, and she felt
1. Communication with nurses, spouse, and lonely if she did not do so.
family, and getting the opportunity to express
her feelings about her situation somewhat
reduced the patient/client’s concerns, which
stemmed from her desire to get attention. Conflicts of interest
She stated that the hope for a bright future The author(s) declared no potential conflicts of inter-
for her children was the incentive for the rest est with respect to the research, authorship, and/or
of her life. publication of this article.
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Multiple Sclerosis Journal—Experimental, Translational and Clinical
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